Breakwater Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockland, Maine.
- Location
- 100 Commons Drive, Rockland, Maine 04841
- CMS Provider Number
- 205124
- Inspections on file
- 26
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Breakwater Commons during CMS and state inspections, most recent first.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Incomplete controlled substance shift count documentation was found on the West, South, and East Units. Surveyors reviewed the Controlled Substances Book and Shift Count pages on med carts and found missing signatures from staff coming on and going off duty, along with entries that lacked the date, time, and/or status of count. The findings were discussed with the Unit Manager, DON, and Administrator.
Kitchen sanitation and food storage deficiencies were observed when multiple food items in storage areas were not dated, labeled, covered, or sealed, and kitchen equipment and surfaces including the slicer, mixer, disposal unit, hood system, stove, fans, and refrigerator/freezer shelving had dried food residue or dirt. Staff were also observed in the kitchen with facial hair and no facial hair protection.
Incomplete neurological and wound documentation was found for two residents with unwitnessed falls and one resident with a right heel pressure injury. Neuro checks after falls were not fully documented at required intervals, and the wound record lacked staging, measurements, and description while the chart contained conflicting pressure injury stages from the RN, NP, and wound clinic records.
The facility failed to ensure IDT review and revision of care plans after MDS assessments for multiple residents. Records showed that for several residents, no IDT meeting was documented within the required 7-day window after quarterly, annual, admission, or significant change MDSs, and in some cases the IDT meeting occurred before the MDS was completed or outside the required timeframe. Staff interviews confirmed that some IDT meetings were completed before the MDSs and others were not completed on time.
Failure to Provide Advance Directive Information: The facility did not ensure that written information about the right to accept or refuse treatment and to formulate an advance directive, or appoint a surrogate, was provided to two residents reviewed for advance directives. The EMR for both residents lacked evidence that the facility offered or reviewed advance directive information with the resident and/or resident representative, and the DON confirmed the records showed no evidence of the opportunity to complete advance directives.
Failure to Complete MDS After Resident Death: The facility did not complete an MDS for a resident after the resident died. Record review showed the resident’s death in mid January of 2026, and the MDS record lacked evidence of completion. The DON later reviewed the chart and confirmed the MDS was not completed after the resident died.
A facility failed to keep the resident environment free of accident hazards when two 8.8-ounce spray bottles of Febreze Air Effects Gain Original were observed sitting on a shelf at the foot of a resident's bed. An LPN confirmed that confused residents moved around the unit and could enter rooms and access hazardous chemicals.
A resident with PTSD and trauma related to combat/exposure to war had documented triggers including loud noises and misplaced items, but the care plan lacked evidence of a trauma-informed care plan that included those triggers. The SW confirmed the care plan did not reflect the resident's triggers that might cause re-traumatization.
Improper Storage of Controlled Substances and Medications: Surveyors found lorazepam oral concentrate stored in unaffixed plastic boxes inside unlocked medication refrigerators on two units, and medication refrigerators on three units were dormitory-type units with ice buildup while also storing medications, including insulin. Staff confirmed the refrigerators were not locked and that any nurse or medication tech could access the medication rooms and remove the controlled medication.
Surveyors observed that multiple rooms housing residents with Foley catheters lacked required signage and accessible PPE for Enhanced Barrier Precautions, as outlined by CDC guidance. Staff interviews revealed confusion about infection control protocols and a lack of awareness regarding which residents required contact precautions, resulting in a failure to follow established infection control policies.
A resident with a Foley catheter experienced pain and lack of urine flow, leading an LPN to change the catheter after an unsuccessful flush. The LPN did not verify the existence of a provider order for the as-needed catheter change, and nurse practitioners confirmed they were not notified or consulted prior to the intervention.
A resident with an indwelling urinary catheter did not have complete or accurate clinical records, including missing intake and output documentation on several scheduled dates, a delayed and improperly entered nursing progress note about catheter care, and a lack of documented provider order for a catheter insertion. These lapses were confirmed by facility staff and resulted in incomplete records.
The facility did not properly implement its QAPI program to ensure accurate and complete intake and output (I & O) documentation, resulting in ongoing incomplete records for residents requiring I & O tracking. This deficiency was confirmed by surveyors through record review and staff interview.
The facility did not provide required education on urinary catheter care and infection prevention to both its own and agency nursing staff after an incident. Despite preparing educational materials, no training or competency checks were conducted before the survey, and agency staff did not receive orientation or relevant education from the facility. Interviews confirmed that staff lacked training and understanding of key infection prevention practices.
The facility failed to provide residents and/or their representatives with written information about their rights to accept or refuse treatment and formulate an advance directive. This affected 11 out of 13 residents reviewed, as confirmed by the Quality Improvement Specialist.
The facility failed to conduct timely interdisciplinary team (IDT) meetings and document resident participation or invitations after Minimum Data Set (MDS) assessments for several residents. This deficiency affected residents with various medical conditions, including Parkinson's Disease and Chronic Respiratory Failure. Interviews with staff confirmed the lack of timely meetings and documentation, highlighting a systemic issue in the care planning process.
The facility failed to administer insulin timely relative to meal delivery for a diabetic resident, did not obtain necessary physician orders for side rail use for two residents at risk of falls, and lacked physician orders for medications kept at the bedside for two residents. These deficiencies were confirmed by facility staff during interviews.
The facility failed to maintain a sanitary environment for residents requiring respiratory care, with multiple instances of improper storage and maintenance of oxygen and nebulizer equipment. A resident's oxygen tubing was found on the floor, another's nebulizer equipment was unlabeled, and others had discrepancies in their treatment records. These issues were confirmed by the DON, indicating non-compliance with facility policies.
The facility failed to properly label and store medications, including an undated Tuberculin vial and unrefrigerated Acidophilus, leading to deficiencies in medication management. Expired medications were also found on medication carts, which were addressed by staff upon discovery.
The facility failed to properly label and date food items in storage areas and did not maintain a sanitary environment during meal service. Unlabeled and undated food items were found in various storage areas, and a Dietary Aide was observed handling food without proper hand hygiene. The aide had not received training on hand hygiene or safe food handling practices.
The facility did not ensure that CNAs completed the required 12 hours of annual in-service education training. A review of records for five CNAs, employed for over a year, showed they did not meet the 2024 training requirements. The Administrator confirmed these findings during an interview with surveyors.
The facility failed to maintain a sanitary environment on the East and South units, with observations of improperly stored commode buckets and bed pans in bathrooms. The Director of Nursing confirmed the improper storage during discussions with surveyors.
The facility failed to develop comprehensive care plans for residents with specific medical needs, including those with cardiac pacemakers, hospice care, respiratory needs, and psychotropic drug use. These deficiencies were confirmed through staff interviews and record reviews.
The facility did not complete an annual performance evaluation for a CNA employed for over a year. The CNA, hired in early 2021, lacked a 2024 evaluation, as confirmed by the President of Clinical Services and Quality Improvement.
The facility failed to provide evidence of required members' attendance at 3 out of 4 QAPI meetings. The Administrator could only produce an attendance sheet for one meeting, and the previous DON was assumed to be taking attendance. The Medical Director was absent from one meeting, and infection preventionists were not included in any meetings, leading to a deficiency in the QAPI program.
A facility failed to adhere to its Infection Control Program during the administration of subcutaneous insulin to a resident. A registered nurse did not perform hand hygiene or don gloves before administering Novolog Insulin, contrary to the facility's policy. The nurse acknowledged the oversight, and the incident was discussed with the President of Quality Improvement and Nursing Services.
A facility failed to follow its Immunization Policy for a resident, as there was no evidence that the resident's PCV 20 and Influenza immunizations were current, offered, or administered. The policy requires documentation of vaccine information receipt and understanding, as well as proof of vaccination, contraindication, or refusal. This deficiency was confirmed during an interview with the Quality Improvement Specialist.
The facility did not follow its Immunization Policy for a resident, as there was no documentation in the clinical record of the COVID vaccine being current, offered, or administered. The policy requires that residents receive the Vaccine Information Statement (VIS) and that their records reflect vaccination status, medical contraindications, or refusals. This deficiency was confirmed in an interview with the Quality Improvement Specialist.
A facility failed to notify a resident's representative of a significant decline in the resident's condition, resulting in the representative not being present at the time of death. Despite documented observations of the resident's difficulty swallowing and lethargy, there was no record of family notification until after the resident's passing. This deficiency was discussed with the facility's President of Quality Improvement and Nursing Services.
A facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for a resident who began receiving hospice services. The assessment, required to ensure coordinated care, was completed 76 days late, as identified during a review and interview with the President of Quality Improvement and Nursing Services.
Two residents were not treated with dignity and respect in a facility. One resident, with severe cognitive impairment, was left on a bedpan for over an hour due to staff communication failure. Another resident was verbally abused by a CNA, who was overheard using derogatory language. The incidents involved agency staff and highlighted deficiencies in resident care.
The facility failed to adhere to professional standards for food service safety by delivering meals in an unsanitary manner. A CNA was seen carrying an uncovered plate of pot pie and dessert to a resident's room. The dietary aide confirmed that meals were typically delivered this way. When questioned, a CNA placed a cover over the next meal tray, and another CNA asked if all items should be covered, to which the surveyor confirmed they should be.
A facility failed to implement a baseline care plan within 48 hours of admission for a resident with multiple diagnoses, including Diabetes Mellitus and chronic kidney disease. The care plan lacked necessary goals and interventions for diabetes and nutrition, despite active medication orders. The DON confirmed these omissions during a surveyor interview.
The facility failed to maintain a comfortable environment in the Memory Care unit, where a resident receiving hospice care was found in a very cold room due to the air conditioning being set to 68°F. This was a result of some CNAs turning on the AC at night to prevent residents from wandering. The issue was known to the DON and addressed in a meeting, but it was unclear if the practice had stopped.
The facility failed to update care plans and monitor residents for side effects of psychotropic medications. A resident with dementia was not monitored for medication side effects, and another resident's care plan lacked fall prevention measures. Additionally, a resident requiring incontinence care did not receive it as per the care plan. These deficiencies were confirmed by the DON during a survey.
The facility failed to implement its grievance policy, resulting in a 30-day delay in responding to a grievance filed on behalf of a resident. The grievance policies provided to the complainant were inconsistent, with one stating a 15-day response time and another indicating a reasonable time frame without specification. Interviews revealed that the responsibility for handling grievances had shifted from the Social Worker to the DON, who believed a 30-day response was reasonable, leading to the deficiency finding.
A resident with dementia and high fall risk was found on the floor with a head laceration after being left unattended in a Broda chair. The injury required hospital evaluation, but the facility failed to report it to the state as required.
A resident, who is a high fall risk and not cognitively intact, was found on the floor with a head laceration after being left unattended in a Broda chair. The resident required hospital transfer for evaluation and treatment. The facility did not investigate the injury, as confirmed by the Administrator.
A facility failed to maintain complete and accurate clinical records for a resident with neurogenic bladder, who was not cognitively intact and dependent on staff for all ADLs. The care plan required frequent incontinence checks and changes, but records showed care was provided less frequently than needed. The DON confirmed the resident should have been toileted or changed more often than documented.
The facility failed to ensure a call bell was accessible to a visually impaired resident with left-sided hemiplegia and cognitive deficits. Despite staff awareness of the issue and the resident's attempts to keep the call bell within reach by wrapping the cord around their neck, no effective alternative solution was provided.
The facility failed to notify the State Agency after two falls that resulted in head injuries for two residents. One resident, who is not cognitively intact, was found on the floor with a brain bleed and was admitted to the emergency room. Another resident, who is nonverbal and dependent on all ADLs, fell from a lift during a transfer and sustained a head injury. The DNS confirmed that these incidents were not reported as she did not believe they were reportable.
The facility failed to thoroughly investigate two falls with head injuries involving two residents. Both residents' clinical records lacked evidence of incident reports, and staff interviews revealed inconsistencies and a lack of proper documentation. The DNS admitted that the facility did not thoroughly investigate the incidents.
The facility failed to update care plans for three residents, leading to deficiencies in fall management and psychotropic medication use. One resident experienced a brain bleed after a fall, another fell from a lift, and a third exhibited unsafe behavior with the call bell. Staff interviews confirmed that care plans were not updated to reflect the residents' current needs.
A resident exhibited symptoms of a hemorrhagic stroke, including left-sided weakness, slurred speech, and facial drooping, but the physician was not notified until approximately 9:00 a.m., despite symptoms being noted between 7:30 a.m. and 8:00 a.m. The resident was sent to the emergency department at 10:21 a.m., and the clinical record lacked timely documentation of notification to the physician and resident representative.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
Incomplete Controlled Substance Shift Count Documentation
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to allow accurate reconciliation. During medication storage observations and record review on the West Unit, South Unit, and East Unit, surveyors reviewed the Controlled Substances Book and Shift Count pages on the medication carts and found multiple instances where the person coming on duty or going off duty did not sign the Shift Count page documenting that the controlled substances count had been completed at shift change. On the West Unit, surveyors found missing signatures for counts completed on several dates, along with multiple incomplete entries that lacked the date, time, and/or status of count. On the South Unit, surveyors found missing signatures for both incoming and outgoing staff on several shift counts, as well as incomplete entries that lacked date, time, and/or status of count. On the East Unit, surveyors found a missing signature for an outgoing staff member on one shift count and incomplete entries that lacked the time and status of count. The findings were discussed with the Unit Manager, DON, and Administrator during the survey.
Kitchen Sanitation, Food Storage, and Facial Hair Protection Deficiencies
Penalty
Summary
The facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure food items were properly dated, labeled, and/or sealed. During an initial kitchen tour, a surveyor observed three large bags of cereal in the dry storage room that were not dated; two packages of waffles in a reach-in freezer that were not labeled and dated; a large bag of diced onions in the walk-in refrigerator that was not labeled; a pan of beans that was not covered or sealed; a package of wraps in the walk-in freezer that was not labeled and dated; and large bins of flour, sugar, and gluten free flour that were not dated. The gluten free flour bin also had a scoop inside it. The surveyor also observed the food slicer, food mixer, and food disposal unit with dried food particles and dried liquid residue on them, two circular floor fans that were dusty and dirty, chemicals stacked on the floor instead of being stored in a metal cabinet, a dusty and dirty hood system, and food and debris on the floor around and under the cook stove. The cook stove itself had dried food particles and dried liquid residue on the front and surface. In addition, a male cook with facial hair was observed not wearing facial hair protection. Later observations in the East, South, and [NAME] unit refrigerator/freezer shelving found dried food particles and dried liquid residue, and a follow-up kitchen visit found two male employees with facial hair in the kitchen without facial hair protection.
Incomplete Neurological and Wound Documentation
Penalty
Summary
Clinical records were incomplete and did not contain accurate information for residents reviewed for neurological assessments and pressure ulcer documentation. The facility’s Fall Management Policy required a neurological assessment tool for falls with a known head bump, and the Neurological Assessment Policy required neurological signs to be monitored and recorded for at least 12 hours after suspected head trauma, with checks documented at specified intervals in the EMR. Resident #105 sustained an unwitnessed fall at 4:00 a.m. on 2/15/26, and the neurological assessment record lacked evidence of fully completed 30-minute and 1-hour checks. The same resident sustained another fall at 1:20 p.m. on 2/15/26, and the neurological assessment record lacked evidence of fully completed 1-hour and 4-hour checks. The DON confirmed during interview that the 30-minute and 1-hour checks were not fully complete for the first fall and that the 1-hour and 4-hour checks were not fully completed for the second fall. Resident #78 sustained unwitnessed falls on 11/19/25 at 2:45 p.m., 2/24/26 at 18:22, and 3/3/26 at 11:31 p.m., and the neurological assessments lacked evidence of fully completed 30-minute and 1-hour checks. For Resident #9, who had diagnoses including a stage 4 pressure injury of the right heel, the daily wound documentation lacked the pressure injury stage, measurements, and wound description. The resident’s record also contained conflicting wound staging information, including references to stage 2, stage 3, and stage 4 in different documents, while the DON stated the facility does not reverse-stage wounds and expected daily wound evaluation documentation to include staging and description.
Failure to Hold Timely IDT Meetings After MDS Assessments
Penalty
Summary
The facility failed to review and revise care plans by an interdisciplinary team (IDT), including resident and/or representative participation to the extent possible, after MDS assessments for 14 of 21 residents reviewed. The report states that for multiple residents, quarterly, annual, admission, or significant change MDS assessments were completed, but the record lacked evidence that an IDT meeting occurred within 7 days after the assessment. In several cases, the IDT meeting was documented before the MDS was completed, and in other cases the meeting occurred outside the required 7-day window or could not be verified in the record. Examples cited in the report include residents whose records showed no evidence of an IDT meeting after quarterly, annual, admission, or significant change assessments, as well as residents whose IDT meetings were held 1 to 11 days before the MDS completion date or more than 7 days after the assessment. During interviews, the social worker stated that some IDT meetings were completed before the MDS assessments were completed while others were not completed within 7 days following the assessments. The DON also confirmed that an IDT meeting had not taken place during one resident’s admission, and the concerns were discussed with the Administrator.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that written information about the right to accept or refuse medical or surgical treatment and to formulate an advance directive, or appoint a surrogate, was provided to the resident and/or resident representative for 2 of 4 residents reviewed for advance directives. Resident #15, admitted in 10/2025, had no evidence in the electronic medical record that the facility offered or reviewed advance directive information with the resident and/or resident representatives or provided written information about the right to formulate an advance directive. Resident #78, admitted in 1/2025, also had no evidence in the electronic medical record that the facility offered or reviewed advance directive information with the resident and/or resident representatives or provided written information about the right to formulate an advance directive. During an interview on 4/8/26 at 11:48 am, the DON confirmed that both residents' records showed no evidence of the opportunity for filling out advance directives.
Failure to Complete MDS After Resident Death
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) after Resident #97 died in mid January of 2026. Review of the resident’s clinical record showed the death, and review of the MDS record showed no evidence that an MDS was completed upon the resident’s death. During an interview on [DATE] at 2:15 p.m., the DON reviewed the record and confirmed that an MDS was not completed after the resident died.
Improper Storage of Chemical Spray Bottles in Resident Room
Penalty
Summary
The facility failed to ensure that the resident environment was free of accident hazards related to chemical storage for 2 of 2 observations on 1 of 4 survey days. The Safety Data Sheet for Febreze Air Effects Gain Original stated that eye contact requires immediate rinsing with plenty of water and medical attention if irritation persists, while ingestion was not an expected route of exposure. On 4/6/26 at 9:40 a.m., a surveyor observed two 8.8-ounce spray bottles of Febreze Air Effects Gain Original sitting on a shelf at the foot of a resident's bed in resident room [ROOM NUMBER]. At 9:46 a.m., an LPN confirmed the observation and stated that confused residents moved around the unit and could enter residents' rooms and access hazardous chemicals. The Administrator was informed of the finding at 10:20 a.m.
Failure to Include PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to identify a resident's current PTSD/trauma diagnosis to determine what triggers might cause re-traumatization for Resident #74. Record review showed the resident was admitted in 2023 with a diagnosis of PTSD, and a quarterly MDS completed on 4/8/26 coded an active diagnosis of Post Traumatic Stress Syndrome. The resident's trauma screen documented trauma related to combat/exposure to war and identified triggers including loud noises and when things were missing or misplaced in the room. However, the care plan updated on 3/6/2026 lacked evidence that a trauma-informed care plan was established to include these triggers. During an interview on 4/8/26 at 3:04 p.m., the Social Worker confirmed that the care plan lacked evidence of the resident's triggers that might cause re-traumatization.
Improper Storage of Controlled Substances and Medications
Penalty
Summary
The facility failed to store controlled substances and other medications properly in medication storage refrigerators on the East Unit, [NAME] Unit, and South Unit. During observations, surveyors found lorazepam oral concentrate, a Schedule IV controlled medication, stored in unaffixed plastic boxes inside unlocked refrigerators in the South Unit medication room and the [NAME] Unit medication storage room. Staff observed that the South Unit medication room refrigerator contained three 30 mL vials of lorazepam in a plastic box with a handle, and the [NAME] Unit refrigerator contained four 30 mL boxes of lorazepam in an unaffixed plastic tackle-type box. Staff also confirmed that the refrigerators were not locked and that the boxes containing lorazepam were not affixed. Surveyors also observed that the medication refrigerators on the East Unit, [NAME] Unit, and South Unit were dormitory-type refrigerator/freezer units with ice buildup in the freezer compartments. Medications, including insulin, were stored in these refrigerators. During interviews, the DON stated that medication techs and nurses had badge access to all medication rooms, and staff on the South Unit stated they did not keep the refrigerator locked and did not know where the refrigerator keys were. The South UM confirmed that any nurse or medication tech from any unit could access the South Unit medication room and remove the unaffixed box containing lorazepam.
Failure to Implement Infection Control Precautions for Residents with Indwelling Catheters
Penalty
Summary
Surveyors found that the facility failed to implement and maintain an effective infection prevention and control program for residents with indwelling Foley catheters. Observations revealed that multiple resident rooms lacked required signage indicating the type of precautions and necessary PPE, as recommended by CDC guidance for Enhanced Barrier Precautions. In several cases, there was no PPE available outside the resident rooms, and signage was either missing, improperly placed, or not visible at the entrance. These deficiencies were confirmed by the Quality Improvement Specialist during the survey. Additionally, interviews with staff, including the Director of Nursing and Infection Preventionist, revealed a lack of awareness regarding the location of reference materials and the current status of residents on transmission-based precautions. Record review showed that residents with indwelling catheters, including those with active infections such as urinary tract infections caused by multidrug-resistant organisms, were not placed on appropriate contact precautions as required by facility policy and CDC guidelines. Staff interviews indicated that frontline caregivers were not informed about residents' precaution status, and there was confusion among leadership regarding the implementation of infection control protocols. These findings were based on direct observation, record review, and staff interviews, demonstrating a failure to follow established infection control policies for residents at risk of transmitting infectious diseases.
Foley Catheter Changed Without Provider Order
Penalty
Summary
A deficiency occurred when a resident with a history of benign prostatic hyperplasia, urinary retention, urinary tract infection, and an indwelling Foley catheter experienced pain and lack of urine flow from the catheter. Nursing documentation indicated that the nurse attempted to flush the catheter without relief and subsequently changed the Foley catheter, noting the resident's pain was relieved and urine output was restored. However, there was no evidence in the clinical record of a provider order authorizing this as-needed catheter change. Interviews with nurse practitioners confirmed they were not aware of the catheter change at the time and had not provided an order for it. The LPN involved stated she used a PRN order to change the catheter but did not verify the existence of such an order prior to the intervention.
Incomplete and Inaccurate Clinical Record Documentation for Catheterized Resident
Penalty
Summary
The facility failed to ensure that clinical records for a resident with an indwelling urinary catheter were complete and accurate. Specifically, there were multiple instances where intake and output (I&O) documentation was missing from the Treatment Administration Records (TAR) on several scheduled dates, despite active physician orders requiring I&O to be recorded twice daily. The Regional Quality Improvement Specialist confirmed that I&O should be documented on the TAR by nursing staff, including information provided by CNAs, as the provider reviews the TAR for urinary output. Additionally, a nursing progress note regarding the resident's catheter care was entered several days after the event occurred, without being marked as a late entry. The note described the removal and reinsertion of a catheter due to the resident's complaint of urinary discomfort and lack of urine drainage, but was not documented until five days later. Furthermore, there was no evidence of a provider order for the catheter insertion on the date it was performed, although the nurse stated a verbal order had been received but not entered. These documentation lapses resulted in incomplete and inaccurate clinical records for the resident.
Failure to Implement QAPI for Accurate I & O Documentation
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) program to ensure compliance with its Plan of Correction (POC) for F-842, specifically regarding the documentation of intake and output (I & O) for residents. During a revisit survey, surveyors found that I & O documentation remained incomplete and inaccurate, despite previous corrective actions outlined in the POC. This deficiency was confirmed through record review and interview with the Regional Quality Improvement Specialist, indicating that the required processes for accurate I & O tracking and documentation were not consistently followed.
Failure to Implement and Maintain Effective Staff Training on Urinary Catheter Care and Infection Prevention
Penalty
Summary
The facility failed to implement and maintain an effective training program for nursing staff, specifically in the areas of urinary catheter care and infection prevention, following a facility-reported incident. Despite the facility's 5-day follow-up indicating that licensed staff would be educated on Foley catheter policies and procedures, interviews with staff and management revealed that no education had been provided prior to the survey. Educational materials were prepared and scheduled for future training, but staff, including those directly involved in the incident, confirmed they had not received any education or competency checks related to urinary catheter care. The Director of Nursing Services and the Educator both acknowledged that while resources were gathered, no directive was given to begin education, and the planned training had not been implemented. Additionally, the facility did not provide orientation or education on urinary catheter care and infection prevention to agency nursing staff, relying solely on competencies provided by the staffing agency. Review of agency staff records showed a lack of evidence for education on urinary catheter care. Interviews with agency LPNs confirmed they had not received any training from the facility on catheter care, transmission-based precautions, or enhanced barrier precautions. One LPN demonstrated a lack of understanding of enhanced barrier precautions, indicating gaps in knowledge and training among both facility and agency staff.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with written information regarding their rights to accept or refuse medical or surgical treatment, formulate an advance directive, or appoint a surrogate. This deficiency was identified for 11 out of 13 residents reviewed for advance directives. The facility's policy, dated 10/18, mandates that upon admission, residents should be informed and provided with information about advance directives. However, the review of the electronic medical records for these residents showed a lack of evidence that such information was offered or reviewed with them or their representatives. During an interview, the Quality Improvement Specialist confirmed that the residents and/or their representatives were not provided with the necessary written information concerning their rights to formulate an advance directive. This oversight affected multiple residents, including those identified as Resident #13, #79, #16, #84, #17, #83, #86, #54, #85, #37, and #33, indicating a systemic issue in the facility's admission process regarding advance directives.
Failure to Conduct Timely IDT Meetings and Document Resident Participation
Penalty
Summary
The facility failed to review and revise care plans by an interdisciplinary team (IDT) meeting, which included the participation of the resident and their representative, after each Minimum Data Set (MDS) 3.0 assessment for 10 of 26 residents. The facility's policy requires that a comprehensive person-centered care plan be developed within seven days after the completion of the comprehensive assessment. However, the records for several residents, including those with diagnoses such as Parkinson's Disease and Chronic Respiratory Failure, lacked evidence of timely IDT meetings or invitations to residents and their representatives. For instance, Resident #73, who is cognitively intact, was not invited to their IDT meeting, and Resident #79's record lacked evidence of an IDT meeting within seven days of their quarterly MDS assessment. Similarly, Resident #90 was unsure if an IDT meeting occurred, and the facility failed to document attendance or meeting details. Other residents, such as Resident #28 and Resident #51, also experienced delays in IDT meetings or lacked documentation of their participation or invitation. The facility's failure to hold timely IDT meetings and document resident participation or invitations was confirmed through interviews with staff, including the President of Quality Improvement and Nursing Services and the Social Worker. This deficiency affected residents with various medical conditions, including dementia and post-operative recovery, and highlighted a systemic issue in the facility's care planning process.
Deficiencies in Insulin Administration, Falls Management, and Medication Orders
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, particularly in the areas of nutrition and falls management. For one resident with diabetes, the facility did not administer rapid-acting insulin in a timely manner relative to meal delivery. The resident received insulin at 7:20 a.m., but did not receive their breakfast until 8:45 a.m., which is 1 hour and 25 minutes later. This delay in meal delivery after insulin administration was acknowledged by the Registered Nurse, who was unable to verify the exact time of insulin administration due to not recording it. In the area of falls management, the facility did not obtain necessary physician orders for the use of side rails for two residents at risk of falls. One resident with hemiplegia and dementia was observed with side rails in use, but their clinical record lacked evidence of a physician's order for the side rails, informed consent, and quarterly screenings. Similarly, another resident with dementia and a history of falls was observed with side rails, but their record also lacked a physician's order and informed consent for side rail use. Additionally, the facility failed to obtain physician orders for medications kept at the bedside for two residents. One resident had Flonase and Ocu Soft Lid Scrub at their bedside without a physician's order or a self-administration screen. Another resident had an Albuterol inhaler at their bedside, which they used as needed, but there was no physician order to keep the medication at the bedside or evidence of self-administration documentation. These findings were confirmed by facility staff during interviews.
Improper Storage and Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment for residents requiring respiratory care, as observed in multiple instances involving oxygen and nebulizer equipment. Resident #54's oxygen nasal cannula tubing was found on the floor with a date label indicating it had not been changed according to the physician's order. Similarly, Resident #70's nebulizer equipment was improperly stored and unlabeled. Resident #17's oxygen and nebulizer tubing were not changed or stored as per the care plan, with discrepancies noted in the treatment administration records. These observations were confirmed during a tour with the Director of Nursing. Resident #13's nebulizer equipment was stored without a barrier, risking cross-contamination, as confirmed by the Director of Nursing. Resident #42's oxygen tubing and antimicrobial bag were not changed weekly as required, with the tubing found on the floor and later improperly stored. The Director of Nursing acknowledged these findings during an interview. These deficiencies highlight a pattern of non-compliance with the facility's policies on respiratory care equipment maintenance and storage, potentially increasing the risk of infection transmission among residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to deficiencies in medication management. During an observation of the South unit nurse treatment cart, a vial of Tuberculin Purified Protein Derivative was found opened and undated, contrary to the manufacturer's instructions which required it to be stored between 36-46 degrees Fahrenheit and discarded after 30 days once opened. The Registered Nurse confirmed the vial was not labeled or stored correctly and disposed of it immediately. Further observations revealed additional issues with medication storage. On the South unit medication cart, an opened bottle of Acidophilus w/Pectin, which required refrigeration after opening, was improperly stored. Additionally, expired medications, including Famotidine 10mg and Loratadine 10mg, were found on the cart. The Certified Medication Technician removed these items upon discovery. Similarly, on another unit, an opened bottle of Acidophilus probiotic was found unrefrigerated, contrary to the manufacturer's instructions. These findings were discussed with the President of Quality Improvement and Nursing Services.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in various storage areas, including the stand-up freezer, dry storage room, and walk-in refrigerator. During a kitchen tour, surveyors observed several unlabeled and undated food items, such as a bag with an unknown brown crumbly substance, a bag of chocolate icing, and multiple bags of freezer-burned bananas. Additionally, the walk-in refrigerator contained undated and unlabeled items, including crumbled bacon, various vegetables, pork chops, a sandwich, and other unidentifiable substances. The Dietary Manager confirmed these findings during the survey. Furthermore, the facility did not maintain a sanitary environment during a dining observation. A Dietary Aide was observed handling food and utensils without proper hand hygiene, including drinking chocolate milk, discarding the cup, and then donning gloves without sanitizing hands. The Dietary Aide admitted to not receiving education on hand hygiene since starting employment. The facility's records showed that while the aide received the Infection Control/Exposure Control Plan, there was no evidence of training on hand hygiene or safe food handling practices. These findings were reviewed with the Quality Improvement Specialist and the Dietary Manager.
Failure to Provide Required CNA Training
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service education training. A review of employee education records for five randomly selected CNAs, all employed for more than one year, revealed that none had completed the necessary continuing education for the year 2024. The CNAs in question were hired between 1994 and 2021, and their records lacked evidence of compliance with the training requirements. During an interview, the Administrator confirmed these findings in the presence of four surveyors.
Improper Storage of Hygiene Equipment in Facility Bathrooms
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East and South units over a three-day survey period. On the East Unit, multiple observations revealed that shared bathrooms in several rooms had commode buckets and wash basins improperly stored on the floor. These observations were confirmed during a discussion between the surveyor and the Director of Nursing. On the South Unit, similar issues were noted, with uncovered bed pans improperly stored on shelves and shower shelves, sometimes containing briefs. The Director of Nursing confirmed during an interview with surveyors that the bed pans were not stored properly.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing specific medical needs. Resident #86 and Resident #83, both with cardiac pacemakers, lacked care plans addressing their cardiac conditions. Despite being followed by cardiology, Resident #86's medical record did not include a care plan for the pacemaker, a deficiency confirmed by the President of Quality Improvement and Nursing Services. Similarly, Resident #83's medical record also lacked a care plan for the pacemaker, as confirmed by the same official and the Quality Improvement Specialists. Additionally, Resident #243, who was admitted to hospice services, did not have a care plan for hospice or end-of-life care, a deficiency noted after the resident's passing. Residents #54 and #16, both receiving oxygen therapy for respiratory conditions, also lacked care plans for their oxygen usage. Furthermore, Resident #71, who was assessed for psychotropic drug use, did not have a comprehensive care plan addressing this area. These deficiencies were confirmed through interviews with various facility staff, including the Director of Nursing and the President of Quality Improvement and Nursing Services.
Failure to Conduct Annual CNA Performance Evaluation
Penalty
Summary
The facility failed to conduct an annual performance evaluation for a Certified Nursing Assistant (CNA) who had been employed for more than one year. Specifically, CNA #4, who was hired on February 8, 2021, did not have a performance evaluation completed for the year 2024. This deficiency was confirmed during an interview with the President of Clinical Services and Quality Improvement, who acknowledged the absence of the required evaluation documentation for CNA #4.
QAPI Meeting Attendance Deficiency
Penalty
Summary
The facility failed to demonstrate compliance with the Quality Assurance and Performance Improvement (QAPI) requirements by not providing evidence of the required members' attendance at 3 out of 4 quarterly meetings. The Administrator, during an interview, could only provide an attendance sheet for one meeting, indicating a lack of documentation for the others. It was revealed that the previous Director of Nursing was responsible for preparing presentations and was assumed to be taking attendance, but this was not verified. Additionally, the Medical Director was absent from the third quarter meeting, and the infection preventionists were not included in any of the four quarterly meetings reviewed. This lack of documentation and attendance by key members led to the deficiency in the facility's QAPI program.
Infection Control Breach During Insulin Administration
Penalty
Summary
The facility failed to maintain an effective Infection Control Program during the administration of subcutaneous injected medication for a resident. The facility's policy on Injectable Medication Administration, revised in January 2018, requires that hands be washed before putting on examination gloves and upon removal for the administration of injectable medications. During an observation, a registered nurse prepared Novolog Insulin for subcutaneous injection and entered the resident's room without performing hand hygiene or donning gloves. The nurse then cleansed the resident's right lower abdomen with an alcohol prep and administered the insulin. The nurse confirmed that he should have performed hand hygiene and donned gloves prior to the medication administration. This incident was discussed with the President of Quality Improvement and Nursing Services.
Failure to Implement Immunization Policy for Resident
Penalty
Summary
The facility failed to implement its Immunization Policy for a resident whose immunization records were reviewed. According to the policy, before offering vaccines such as Influenza, Pneumococcal, or COVID, each resident or their legal representative should receive a Vaccine Information Statement (VIS) from the CDC, and the resident's clinical record should document the receipt and understanding of this material. Additionally, the policy requires documentation of whether the resident received the vaccine, if it was contraindicated, or if the resident refused it. The policy also specifies that residents should be offered the Influenza vaccine annually between October 1 and March 31, and the Pneumococcal and COVID vaccines upon admission unless contraindicated or previously administered. In the case of the resident in question, the clinical record indicated that the resident was admitted to the facility, but there was no evidence that the resident's PCV 20 and Influenza immunizations were current, offered, or administered as per the facility's policy. This deficiency was confirmed during an interview with the Quality Improvement Specialist, highlighting a lapse in following the established immunization procedures for the resident.
Failure to Implement Immunization Policy for Resident
Penalty
Summary
The facility failed to adhere to its Immunization Policy for a resident whose immunization records were reviewed. According to the policy, before offering vaccines such as Influenza, Pneumococcal, or COVID, each resident or their legal representative must receive the appropriate Vaccine Information Statement (VIS) from the CDC, and the resident's clinical record should document the receipt and understanding of this material. Additionally, the record should show proof of vaccination, medical contraindication, or refusal. However, for one resident, there was no evidence in the clinical record that the COVID vaccine was current, offered, or administered as per the facility's policy. The deficiency was confirmed during an interview with the Quality Improvement Specialist, where it was noted that the resident's clinical record lacked documentation of the COVID immunization status. This oversight indicates a failure to implement the facility's policy regarding the offering and documentation of vaccines, which is crucial for maintaining the health and safety of residents in the facility.
Failure to Notify Family of Resident's Decline
Penalty
Summary
The facility failed to notify a medical provider and the resident's representative of a significant change in the medical condition of a resident who was under hospice care. The resident, identified as Resident #243, experienced a decline in their ability to swallow, which was documented in nursing notes over several days. Despite these observations, there was no documentation indicating that the resident's representative was informed of the resident's transition from a declining state to an active dying phase. This lack of communication resulted in the resident's representative expressing anger for not being given the opportunity to be present at the time of the resident's death. The nursing notes detailed the resident's condition, including difficulty swallowing and lethargy, and the administration of PRN morphine. Although the doctor was notified of the resident's dietary changes, there was no record of notifying the family about the significant decline. The resident ultimately passed away without family present, and the family was only informed postmortem. This deficiency was discussed with the President of Quality Improvement and Nursing Services, highlighting the lack of documentation and communication regarding the resident's decline.
Failure to Timely Complete Significant Change in Status Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) within the required 14-day period following a resident's enrollment in hospice care. According to the Resident Assessment Instrument (RAI) Manual, a SCSA is necessary when a terminally ill resident begins receiving hospice services to ensure a coordinated care plan between the hospice and the nursing home. In this case, a resident was admitted to hospice on June 19, 2024, but the SCSA was not completed until September 17, 2024, which was 76 days later than required. This oversight was identified during a record review and interview with the President of Quality Improvement and Nursing Services.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect. In the first incident, a resident with severe cognitive impairment and dependent on staff for toileting was left on a bedpan for approximately one and a half hours. The resident's family member discovered the situation and reported it. The facility's internal investigation revealed that the staff failed to communicate effectively about the resident being placed on a bedpan, leading to the oversight. In the second incident, a licensed nurse overheard a CNA verbally abusing another resident by calling them derogatory names and accusing them of making up reasons to use the call light. The resident, who had multiple medical conditions including spinal stenosis and diabetes, did not recall the incident when interviewed. The CNA involved was employed by a travel staffing agency, and the facility was informed of the allegations.
Unsanitary Meal Delivery Observed
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food service safety by delivering meals in an unsanitary manner. During the noon meal service on the East unit, a CNA was observed carrying a tray with an uncovered plate of pot pie and an uncovered dessert down a hallway to a resident's room. Upon returning to the serving line, the CNA mentioned that the resident wanted a salad instead. When questioned by the surveyor, the dietary aide confirmed that meals were always delivered on trays in this manner. Several CNAs were present at the serving line, and when asked if they knew the correct way to deliver trays, one CNA placed a cover over the next meal tray's plate. The CNA who had delivered the uncovered tray inquired if all items were supposed to be covered, to which the surveyor confirmed that food items should indeed be covered. The surveyor discussed the observation with the Administrator, who acknowledged the concerns regarding the delivery of uncovered meals down the hallways.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, as required by their policy. The policy mandates that a baseline care plan should be created based on the admission assessment, physician orders, and resident preferences to ensure a smooth transition of care. This care plan should include initial goals, physician orders, dietary orders, therapy services, social service needs, and PASRR recommendations. However, the care plan for the resident in question, who was admitted with multiple diagnoses including Diabetes Mellitus and chronic kidney disease, lacked goals and interventions specifically related to diabetes and nutrition. During a complaint investigation, it was found that the resident's active orders included medications for managing Type II Diabetes Mellitus and chronic kidney disease. Despite these orders, the baseline care plan did not reflect necessary goals and interventions for managing these conditions. The Director of Nursing confirmed the omission during an interview with surveyors, acknowledging that the care plan did not adequately address the resident's needs in the areas of diabetes and nutrition.
Failure to Maintain Comfortable Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for residents in the Memory Care unit, as evidenced by the complaint investigation. A resident, who was admitted with diagnoses including dementia, anxiety, depression, and was receiving hospice services, was found to be in a room that was very cold. The Memory Care Unit Manager observed that the air conditioning was set to 68°F, which was too cold for the resident. This issue was not isolated, as multiple rooms were found to have their air conditioning set to the same temperature. Further investigation revealed that some CNAs on the overnight shift were intentionally turning on the air conditioning to keep residents in bed and prevent wandering. This practice was confirmed by a staff member who reported that it had been happening multiple times, including as recently as a few days before the survey. The Director of Nursing was aware of the situation and had addressed it in a CNA meeting, but it was unclear if the practice had ceased.
Deficiencies in Care Plan Updates and Monitoring
Penalty
Summary
The facility failed to update and include necessary goals and interventions in the comprehensive care plans for several residents, leading to deficiencies in monitoring and care. Specifically, Resident #1, who has multiple diagnoses including dementia and is receiving hospice care, was prescribed several psychotropic medications. However, there was no documented evidence that the resident was being monitored for potential side effects of these medications, as required by the facility's Psychoactive Medication Use Policy. This lack of monitoring was confirmed by the Director of Nursing during an interview with surveyors. Similarly, Resident #2, also receiving hospice care, was not monitored for side effects of psychotropic medication use, and their care plan lacked goals and interventions related to fall prevention measures, such as the use of a fall mat and bed positioning. Additionally, Resident #3, who requires total assistance for incontinence care, was not receiving care as per the care plan, and there was no evidence of monitoring for side effects of psychotropic medications. These deficiencies were confirmed by the Director of Nursing upon review of the clinical records during the survey.
Failure to Implement Grievance Policy
Penalty
Summary
The facility failed to establish and implement its grievance policy, as evidenced by the handling of a grievance filed on behalf of a resident. The complaint was received by the Department of Licensing, indicating that a grievance was filed on 7/25/24, but no response was received for 30 days. The complainant was provided with two different grievance policies, one stating a response would be received in 15 days and the other indicating a response would be given in a reasonable amount of time, without specifying what that time frame was. The facility's grievance policy dated 10/18 states that grievances should be resolved promptly, with a reasonable time frame agreed upon with involved parties. However, the Resident Admission Packet indicated a response should be given within 15 days. Interviews with facility staff revealed inconsistencies in the grievance process. The Social Worker, who was previously the Grievance Officer, stated that grievances should be responded to within 15 days, while the Director of Nursing (DON), who took over the responsibility, believed 30 days was a reasonable time frame. The DON confirmed receiving the grievance on 7/25/24 but did not file it until the following day due to needing additional information. This discrepancy in policy implementation and communication led to the delay in addressing the grievance, resulting in a deficiency finding during the complaint investigation.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency after a resident, who was a high fall risk, was found on the floor with a head laceration. The incident occurred when the resident, who has dementia, anxiety, depression, and is receiving hospice services, was left unattended in a Broda chair. The resident was discovered face down on the floor with a laceration to the outer eye, requiring transfer to an acute care hospital for evaluation and treatment. The facility's Administrator confirmed during an interview that the injury was not reported to the state, as required.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to investigate an injury of unknown origin involving a resident who was found on the floor with a head laceration. The incident occurred when the resident, who is a high fall risk and not cognitively intact due to dementia, was left unattended in a Broda chair. The resident was discovered face down on the floor with a laceration to the head and right hand, necessitating transfer to an acute care hospital for evaluation and treatment. Despite the severity of the incident, the facility did not conduct an investigation into how the injury occurred, as confirmed by the Administrator during an interview with surveyors.
Incomplete Clinical Records for Incontinent Care
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for a resident reviewed for incontinent care. The resident, who was not cognitively intact and dependent on staff for all Activities of Daily Living (ADL), was admitted with a diagnosis of neurogenic bladder. The care plan indicated that the resident required total assistance for incontinence care, with checks and changes to be made at specific times throughout the day. However, the ADL Verification Worksheet showed that the resident received incontinent care less frequently than required, with records indicating care was provided only one to three times on various days in July. During a review of the clinical record, the Director of Nursing confirmed that the resident should have been toileted or changed at each meal time, first thing in the morning, before bed, and as needed, which was not reflected in the documentation.
Inaccessible Call Bell for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure that a call bell was accessible to a resident with severe visual impairment and left-sided hemiplegia. The resident, who had a history of stroke and cognitive deficits, was observed unable to locate the call bell, which was affixed to the right-side rail behind the elevated mattress and out of reach. Despite the resident's attempts to keep the call bell accessible by wrapping the cord around their neck, staff repeatedly removed it for safety reasons but did not provide an effective alternative solution. Interviews with various staff members, including LPNs, CNAs, and the Facility Nurse Practitioner, confirmed that the resident frequently wrapped the call bell cord around their neck to ensure it was within reach. Staff were aware of the safety risks but had not found a suitable alternative that worked with the current call system. The Division for the Blind had been contacted for assistance, but the resident's daughter canceled the services, and no recommendations were implemented. The Unit Manager and Director of Nursing acknowledged the issue and confirmed that the call bell was not accessible when the resident was sitting up in bed. Despite being aware of the resident's needs and the potential safety hazards, the facility had not made adequate accommodations to ensure the call bell was within the resident's reach at all times. The Social Worker suggested that hand bells might be a viable alternative, but no action had been taken to implement this solution.
Failure to Report Falls Resulting in Head Injuries
Penalty
Summary
The facility failed to notify the State Agency after two falls that resulted in head injuries for two residents. Resident 1, who has a history of falls and requires substantial assistance with Activities of Daily Living (ADLs), was found on the floor in their room after an unwitnessed fall. The resident, who is not cognitively intact, was covered in blood and had a brain bleed, leading to their admission to the emergency room and subsequent transfer to Maine Health. Despite the severity of the incident, the facility did not report the event to the State Agency as required. Similarly, Resident 2, who is nonverbal, dependent on all ADLs, and receiving hospice care for end-of-life, fell from a lift during a transfer. The resident sustained a head injury with visible bleeding. The Director of Nursing (DNS) confirmed during an interview that the facility did not report this incident either, as she did not believe it was reportable. Both incidents highlight a failure in the facility's protocol for reporting significant injuries to the appropriate authorities.
Failure to Investigate Falls with Head Injuries
Penalty
Summary
The facility failed to thoroughly investigate two falls with head injuries involving two residents. Resident 1, who has a history of falls and requires substantial assistance with ADLs, was found on the floor with a head injury and subsequently admitted to the hospital with a brain bleed. The clinical record for Resident 1 lacked evidence of an incident report for this fall. Similarly, Resident 2, who is dependent for all ADLs and has Alzheimer’s disease, fell from a Hoyer lift during a transfer, resulting in a head injury. The clinical record for Resident 2 also lacked evidence of an incident report for this fall. Interviews with staff revealed inconsistencies in the accounts of the incidents and a lack of proper documentation. The Director of Nursing (DNS) was unable to provide written documentation of the investigations and admitted that the facility did not thoroughly investigate the incidents. The Unit Manager, who was new to the role, indicated that it was her responsibility to ensure incident reports were completed but was unaware of the proper procedures. The facility's failure to document and thoroughly investigate these incidents is a clear deficiency in their handling of resident falls and injuries.
Failure to Update Care Plans for Falls and Psychotropic Medication Use
Penalty
Summary
The facility failed to update and implement care plans for three residents, leading to deficiencies in fall management and psychotropic medication use. Resident 1, who had diagnoses including dementia, left-sided hemiplegia, and seizure disorder, experienced an unwitnessed fall resulting in a brain bleed. Despite new physician orders for various medications, Resident 1's care plan was not updated to reflect goals and interventions for the brain bleed, hemiparesis, vision, and chronic kidney disease. This lack of updates was confirmed by the Unit Manager and Director of Nursing (DNS) during interviews. Resident 2, diagnosed with Alzheimer's disease and depression, and receiving hospice care, fell from a lift during a transfer, resulting in a head injury. The care plan for Resident 2, which was last reviewed in March 2024, did not include updated goals and interventions following the fall, nor did it reflect the resident's current transfer and communication status. Interviews with staff confirmed that Resident 2 was nonverbal, dependent on a Hoyer lift for transfers, and unable to use a call bell, yet the care plan was not appropriately updated. Resident 3, with diagnoses including blindness and a history of stroke, had orders for psychotropic medications but continued to exhibit unsafe behavior with the call bell. Despite multiple incidents where Resident 3 wrapped the call bell cord around their neck, the care plan was not updated to address these behaviors and the use of psychotropic medications. Staff interviews revealed that this behavior was known to management, yet the care plan did not reflect the necessary interventions to ensure Resident 3's safety. The Unit Manager confirmed that care plans were not updated within the required timeframe to reflect the residents' current needs.
Failure to Notify Physician and Resident Representative of Significant Change
Penalty
Summary
The facility failed to notify the physician and the resident representative of significant changes in a resident's condition in a timely manner. The clinical record review and interviews revealed that the resident exhibited symptoms of a hemorrhagic stroke, including left-sided weakness, slurred speech, facial drooping, and confusion. These symptoms were first noted between 7:30 a.m. and 8:00 a.m., but the physician was not notified until approximately 9:00 a.m. The resident was eventually sent to the emergency department at 10:21 a.m., but the delay in notification and action was significant. Additionally, the clinical record lacked documentation that the physician and resident representative were notified of the significant change in the resident's condition in a timely manner. Interviews with staff members, including a registered nurse and a certified nurse aide, indicated that there were multiple observations of the resident's deteriorating condition. Despite these observations and concerns expressed by the CNA, the symptoms were initially attributed to low blood sugar, and the appropriate medical response was delayed. The emergency medical services documentation confirmed that the call for transfer to the emergency department was made at 10:21 a.m., with EMS arriving at 10:29 a.m. The surveyor discussed these findings with the facility, highlighting the failure to notify the physician and resident representative promptly.
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The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A resident left their room, exited through an exit door, and was later found outside on facility grounds lying on the grass, after previously being observed in a stairwell and returned to their room while remaining restless. Facility documentation and a SERCA confirmed staff did not re‑evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and had no elopement policy in place. The Administrator and DON acknowledged they knew of the incident when it occurred but did not notify the State agency or submit a 5‑day follow‑up report, as they treated the event as a fall rather than an elopement because the resident was found on facility property.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Failure to Follow Physician Medication and Treatment Orders
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow physician orders for medications and treatments for several residents. One resident had a physician order dated 4/23/26 for Ceftriaxone Sodium 1 gram IM daily for 5 days for a urinary tract infection. Review of the Treatment Administration Record showed the antibiotic was administered on 4/23, 4/24, 4/26, and 4/27, with no evidence of administration on 4/25. The DON confirmed that the ordered dose on 4/25 was not given. Another resident with ongoing issues of constipation and diarrhea had active orders for Loperamide 2 mg PO PRN after loose stool, with one repeat dose allowed, and Sennosides 8.6 mg, 2 tablets PO twice daily for constipation, to be held for loose stools in the last 24 hours. Review of the bowel elimination history and MAR showed repeated instances where Loperamide was given when there was no bowel movement or when bowel movements were normal, and not given after documented loose/diarrhea stools as ordered. Sennosides was administered within 24 hours of loose stools, contrary to the order to hold it under those circumstances. Additionally, this resident had an antibiotic received from the pharmacy on 3/21/26 with a faxed order on 4/1/26 indicating it should be taken every 8 hours for 7 days following a 3/18/26 office visit; however, the MAR showed the first dose was not given until 4/1/26, 12 days after the antibiotic was received from the pharmacy, and the record lacked evidence of timely follow-up with the urologist regarding the antibiotic and progress note. A further deficiency was identified when a resident with a provider response indicating an existing PRN nebulizer order for shortness of breath had no documented PRN nebulizer treatment administered on the date the nurse requested nebulizer treatments for complaints of shortness of breath, despite the active order. In another case, during a medication pass observation, a CNA-M handed a resident a cup containing 14 pills, which the resident placed in the mouth and swallowed all at once with water. This was inconsistent with a physician order dated 4/9/26 specifying that medications were to be given whole with water, one at a time, with the resident in an upright position. The CNA-M later confirmed that the medications had been given all at once rather than one at a time as ordered.
Incomplete and Inaccurate Clinical Records for Medication, Treatment, and Wound Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when multiple active physician orders were not documented as completed on the MAR and TAR for the month of April. For one resident, there was no evidence of documentation for ordered interventions including daily lavage of the left ear with warm water, application of Triad cream to a left buttocks stage 2 area, monitoring for signs and symptoms of respiratory infection/COVID every day and night, use of an air mattress on the bed every shift, documentation of shortness of breath, encouragement of off-loading of the right hip, maintaining the head of bed (HOB) elevated greater than 30 degrees every shift, monitoring for difficulty swallowing food or medications, keeping the HOB upright for one hour after meals, use of a right side half bedrail as an enabler for bed mobility, nurse education that supervision with meals was medically recommended, and being out of bed in a wheelchair for all meals. The DON confirmed that the MAR and TAR lacked evidence of completed documentation for these physician orders. The facility also failed to ensure that a resident’s clinical record contained accurate information regarding wound care. A physician progress note documented that the resident had a stage 2 upper medial posterior thigh pressure ulcer with interval improvement and directed continuation of calcium alginate and island dressing changes and continuation of a foley catheter for moisture management. However, the clinical record showed that the calcium alginate/foam/Tegaderm wound care order had been discontinued earlier and replaced with an order for Triad hydrophilic wound dressing paste, and that the resident’s foley catheter had been removed during a recent hospitalization. The DON confirmed that the provider note did not contain accurate information related to the resident’s current wound care orders.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Resident Found Outside in Snow After Unmonitored Exit Through Unsecured Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents and environmental hazards, resulting in an immediate jeopardy situation. The resident had been admitted following a fall at home with fractured ribs and had diagnoses of Alzheimer’s disease and dementia with psychosis, along with chronic confusion, short-term memory loss, mobility limitations, a history of falls, and a need for cues and assistance with personal care. An admission BIMS score of 8/15 indicated severe cognitive impairment. Despite these conditions and family reports of increased confusion, sundowning, agitation, hallucinations, delusions, and falls, the facility’s elopement risk assessment scored the resident as zero, identifying the resident as not at risk for elopement. The resident was placed in a room directly across from an exit door that did not lock, and both the unit secretary and a CNA expressed concerns about this placement due to the unsecured door and the resident’s diagnoses and behaviors. On the night and early morning in question, staff documented that the resident was restless, had gone into a stairwell earlier, and continued to be confused and hallucinating, including insisting on moving a truck and talking to people who were not there. Video surveillance showed the resident wandering the hallway multiple times between late evening and early morning. At approximately 5:02 a.m., the resident opened the exit door across from the room, exited, and later returned to the room without staff awareness. At approximately 5:08 a.m., the resident again opened the same exit door and exited the unit; this time the resident did not return, and staff were again not observed in the area or aware of the exit. The exit configuration allowed the resident to pass through a first door and then a second door into an enclosed courtyard/patio that locked behind the resident, preventing reentry. At about 5:34 a.m., staff noticed the resident was not in the room and began searching. By approximately 5:38 a.m., video of the courtyard/patio showed staff outside with the resident lying face down on the snow-covered ground, wearing a long-sleeve shirt, pants, and socks, in overnight temperatures recorded at 20 degrees Fahrenheit. The facility’s internal Sentinel Event Root Cause Analysis identified that staff did not re-evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and that there was no elopement policy in place at the time. The DON stated the incident was initially treated as a fall and was not reported to the State Agency because the resident was found on facility property and the facility did not consider it an elopement. Based on these findings, Immediate Jeopardy was called for the facility’s failure to ensure a resident known to be wandering and able to exit through an unsecure door was adequately monitored and supervised.
Failure to Report Resident Elopement and Submit Required Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s elopement and subsequent neglect incident to the State agency within 24 hours and to submit a 5‑day follow‑up report. Facility records, including nursing documentation, video surveillance, written staff statements, and interviews, confirmed that on March 21, 2026, a resident left their room and exited the unit through an exit door, later being found outdoors on facility grounds. A fall/details note documented that the resident was in bed at 5:00 a.m., was not in their room at 5:30 a.m., and was found outside lying on the grass at 5:40 a.m. A late entry note stated the resident had gone into the stairwell, was observed by staff, brought back to their room, and remained restless. A Sentinel Event Root Cause Analysis (SERCA) documented that the resident was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans. The SERCA identified contributing factors and root causes, including that staff did not re‑evaluate the resident when their behaviors changed and that a Roam Alert was not implemented by the nurse on duty after the first wandering incident. The SERCA also stated the facility did not have an elopement policy in place at the time. During an interview on April 8, 2026, the Administrator and DON confirmed they were aware of the incident when it occurred but did not report it to the State agency because the resident was found on facility property and they did not consider the event an elopement, initially treating it as a fall. As a result, the State agency was not notified within 24 hours, and no 5‑day follow‑up report was submitted for this investigated incident of neglect.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
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